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Medicinal Cannabis
Conditions
Chronic Pain
Fibromyalgia
Migraine
Anxiety
Insomnia
Epilepsy
Spasticity
Multiple Sclerosis
Nausea & Vomiting
Cancer
Bowel Disorder
Alzheimhers disease
Others
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Home
Medicinal Cannabis
Conditions
Chronic Pain
Fibromyalgia
Migraine
Anxiety
Insomnia
Epilepsy
Spasticity
Multiple Sclerosis
Nausea & Vomiting
Cancer
Bowel Disorder
Alzheimhers disease
Others
Pricing
About Us
Blog
Contact Us
Home
Medicinal Cannabis
Conditions
Chronic Pain
Fibromyalgia
Migraine
Anxiety
Insomnia
Epilepsy
Spasticity
Multiple Sclerosis
Nausea & Vomiting
Cancer
Bowel Disorder
Alzheimhers disease
Others
Pricing
About Us
Blog
Contact Us
Registration Form
Please complete this form to register with Cannabis Doctor.
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Name
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Gender
*
Male
Female
Are you pregnant?
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Yes
No
Are you breast feeding?
*
Yes
No
Do you have personally or 1st degree family history of Schizophrenia or Psychosis
*
Yes
No
Are you currently using Marijuana (except prescribed medicinal marijuana) or other recreational drugs?
*
Yes
No
Date of birth
*
Address
*
Mobile
*
Email
*
Do you suffer from one or more of these conditions?
*
Chronic pain
Fibromyalgia
Migraine
Anxiety
Epilepsy
Nausea and vomiting from Chemotheraphy
Other condition
Other conditions you are suffering from?
*
Do you have
*
Heart condition
Diabetes
None of above
Any other medical or mental health conditions?
*
Do you
*
Smoke
Drink alcohol
Take Marijuana or other recreational drugs
None of above
Have you ever tried medicinal cannabis and in what form and for what reason
*
What medications are you currently taking?
*
Are you allergic to any anything / medications / other?
*
What is your expectation from taking medicinal cannabis eg Relieve pain / Manage anxiety, etc
*
By submitting this form, I declare that all information I have provided is true and I give informed consent with an appointment with the Doctor, who will advise me and prescribe Medicinal Marijuana as appropriate to manage my condition. I acknowledge that the Doctor is not obliged to prescribe if not appropriate
*
Yes
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